Depressed fracture anterior wall of frontal sinus.  Open reduction and internal fixation


By

Dr. T. Balasubramanian M.S. D.L.O.

Introduction:  Fractures involving the frontal sinus is one of the rare fractures involving the facial bones.  Its close proximity to the frontal lobe of the brain and orbit makes it a difficult one to manage if the posterior table of the frontal bone is also involved in the fracture line. 

This 39 year old male patient was admitted with h/o road traffic accident sustained 15 days back. 

O/E there was an irregular sutured wound seen over the anterior wall of left frontal sinus.  There was also a depression seen over the anterior wall of left frontal sinus.  Crepitus was also elicitable over that area.

These frontal sinus fractures if they involve the frontal sinus mucosa can lead to the formation of troublesome mucoceles / mucopyoceles.  All these cases must be surgically explored to rule out frontal sinus mucosal entrapment. 

The advantages of open reduction include:

1.  The fracture can be reduced under vision

2. Any mucosal entrapment can be easily identified and managed accordingly

3. Frontal sinus can be explored and bony fragments if any inside the sinus can be removed.  Fluid accumulation inside the sinus can also be sucked out.

Open reduction and internal fixation:

Under general anesthesia the fracture site is exposed via a curvilinear incision just under the left eyebrow.  The incision is usually depened up to the level of periosteum.  The periosteum is stripped from the anterior table with the help of a periosteal elevator.  Perfect hemostasis is a must during the whole of this procedure.  Repeated cauterisation of the bleeding points helps a lot in obtaining a dry field. 

The fracture fragment is first disimpacted and elevated using an elvator.  Suction is applied to the frontal sinus.  If damage to the naso frontal duct is suspected then the intersinus septum must also be divided at this stage.  It is always better to remove the intersinus septum as damage to the naso frontal duct could not be easily identified in a CT scan.  Using a small burr a small hole is drilled into the fractured fragment.  While drilling the fractured fragment should be continuously supported by an elevator inserted under the fragment. 
Stainless steel plates and screws can be used to fix the fractured fragments to the adjacent bone.  In this case you can see 2 - 0 proline being used to anchor the fractured fragment.